Off-Pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: Results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial.

BACKGROUND: The Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial compared clinical and angiographic outcomes in off-pump versus on-pump coronary artery bypass graft (CABG) surgery to ascertain the relative efficacy of the 2 techniques. METHODS AND RESULTS: From February 2002 to May 2007, the ROOBY trial randomized 2203 patients to off-pump versus on-pump CABG. Follow-up angiography was obtained in 685 off-pump (62%) and 685 on-pump (62%) patients. Angiograms were analyzed (blinded to treatment) for FitzGibbon classification (A=widely patent, B=flow limited, O=occluded) and effective revascularization. Effective revascularization was defined as follows: All 3 major coronary territories with significant disease were revascularized by a FitzGibbon A-quality graft to the major diseased artery, and there were no new postanastomotic lesions. Off-pump CABG resulted in lower FitzGibbon A patency rates than on-pump CABG for arterial conduits (85.8% versus 91.4%; P=0.003) and saphenous vein grafts (72.7% versus 80.4%; P<0.001). Fewer off-pump patients were effectively revascularized (50.1% versus 63.9% on-pump; P<0.001). Within each major coronary territory, effective revascularization was worse off pump than on pump (all P≤0.001). The 1-year adverse cardiac event rate was 16.4% in patients with ineffective revascularization versus 5.9% in patients with effective revascularization (P<0.001). CONCLUSIONS: Off-pump CABG resulted in significantly lower FitzGibbon A patency for arterial and saphenous vein graft conduits and less effective revascularization than on-pump CABG. At 1 year, patients with less effective revascularization had higher adverse event rates. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00032630.

Off-site percutaneous coronary intervention reduces hospital length of stay in vulnerable patients with acute myocardial infarction.

Primary percutaneious coronary intervention (PCI) is rapidly becoming the preferred therapy for acute ST-segment elevation myocardial infarction (AMI) because of a lower mortality rate and decreased hospital length of stay (LOS) compared with thrombolysis. However, generalizability of these findings beyond randomized trials involving specialized centers has not been well described. Many urban county hospitals care for disadvantaged patients and lack on-site PCI capabilities. Moreover, treatment delays and worse clinical outcomes have been demonstrated in this population. We sought to determine whether a shift from uniform on-site thrombolysis to off-site PCI for disadvantaged AMI patients reduces hospital LOS. We retrospectively reviewed 91 AMI patients presenting to an inner-city hospital without PCI capabilities, comparing 47 consecutive patients treated with off-site PCI with 44 historical controls who received thrombolysis. The primary end point was hospital LOS. Multivariable regression was used to adjust for baseline differences between the groups. Unadjusted median LOS was lower in the PCI group than the thrombolytic group (4 versus 6 days, P = 0.004). These differences remained after adjusting for variation in baseline sociodemographic and clinical characteristics including the presence of cardiogenic shock. Fifteen patients (34%) in the thrombolytic group required urgent catheterization during index hospitalization versus none in the PCI group (P < 0.001). No differences in death or nonfatal reinfarction were noted 6 months after index event. This study supports the usefulness of primary PCI beyond highly selected populations in randomized controlled trials. Specifically, PCI significantly decreases hospital LOS among vulnerable AMI patients.